The Clinical Appeals Process Explained

11-29-2008, 02:03 PM

The clinical appeals process is a lesser known remedy for cases where a veteran and healthcare facility reach an impasse on a clinical issue or a decision on a claim for benefits administered by the Veterans Health Administration (VHA). Clinical issues typically pertain to the question of whether a provision or denial of clinical care could result in a different or improved outcome for a veteran. Claims that are appropriate for the clinical appeals process are those that can be appealed to the Board of Veterans’ Appeals, such as reimbursement for non-VA care not authorized in advance, reimbursement for beneficiary travel expenses or reimbursement for home improvements. Bear in mind that certain issues are not remedied through the clinical appeals process. These include prescription for care disputes or those that involve reconsideration procedures covered under other statutes, such as CHAMPVA and Spina Bifida cases. Similarly, decisions that originated at the Veterans Benefits Administration and were adopted by the VHA for decision-making purposes are not disputed as clinical appeals. In essence, knowing whether you can appeal a clinical decision or claim is the first step in the clinical appeals process.

So what should you do if you find yourself faced with a disputable claim? First note that you have one year from the date of the initial decision to request reconsideration. The request entails submitting a reconsideration request in writing to the Director of the healthcare facility of jurisdiction. You must explicitly state why you feel the decision was made in error and include any new and relevant information not previously considered. Note that any request for reconsideration that does not identify the reason for the dispute will be returned to you without further consideration. Once you file the appeal and any supporting evidence, a new decision will be made by the immediate supervisor of the initial VA decision maker. In some cases, your appeal may include a request for a meeting with the immediate supervisor of the initial VA decision-maker. If granted, the meeting will be taped and transcribed upon request, and a copy of the transcription will be provided to you along with a written decision that affirms, reverses, or modifies the initial decision. Once the new decision is rendered and you are notified, it is imperative that you are fully apprised in writing of further appellate rights for an appeal to the Board of Veterans' Appeals. If you still disagree, the appeal will be forwarded to the next tier in the VHA hierarchy, the Veteran Integrated Services Network (VISN), where it may be reviewed as an Internal Clinical Appeal or by Independent External Review. At this point, a final decision will take 30 to 45 days. If you still disagree, the case is forwarded to the Board of Veterans Appeals for further adjudication. In some cases, a veteran may be advised by a service officer to appeal directly to the BVA versus first appealing to the VISN.

Fair and impartial review of disputes regarding clinical determinations is a right due to every veteran who receives care within the VA Healthcare System. As such, the clinical appeals process is an important part of preserving the integrity of the veteran-VA facility relationship. By understanding the clinical appeals framework, a veteran is better equipped to influence decisions that may impact quality of care and clinical outcomes. For those who disagree with a clinical decision and want to appeal, they should stop by or contact the nearest PVA National Service Office in your area to get started. ☺

Comment

Do you have a SCI? (it sure helps if you complete your profile) Are you a PVA member? Your best bet for appeals is to get your PVA National Service Officer (NSO) on board to help you with any appeal process. It doesn't cost you anything, and your NSO can act as your agent with all the mess of an appeal.

(KLD)

The SCI-Nurses are advanced practice nurses specializing in SCI/D care. They are available to answer questions, provide education, and make suggestions which you should always discuss with your physician/primary health care provider before implementing. Medical diagnosis is not provided, nor do the SCI-Nurses provide nursing or medical care through their responses on the CareCure forums.

Comment

I have same question as wesaidso1: I see no time limit for deciding a request for reconsideration unless somewhere in the US code there is some kind of provision for something like "when no time limit is set forth". I want to "appeal" an issue involving issuance of shoes. But I do not have any kind of formal decision from which to appeal, just secure written messages! The only way I see to obtain a decision is a request for reconsideration. So: Is there a time limit for a VA facility director to respond to a request for reconsideration or can he/she frustrate the veterans's effort by simply never issuing a decision?

Comment

I am assuming you are appealing a medical decision or something like a prescription or durable medical equipment decision? The medical center director and their dept. in the VA (VHA = Veterans Health Administration) has nothing to do with benefits decisions such as compensation/pension, etc. etc. That is all done through the VBA (Veterans Benefits Administration).

Do you have a SCI? If so, you should be working with your PVA NSO on any appeals. If you don't have a SCI (which is what is indicated in your profile), this site if for those with paralysis due to spinal cord injury or disease. You should deal with your own veterans service organization (such as DAV, VFW, etc.) as they all have NSOs (although many are not nearly as good or effective as the ones who work for the PVA, in my experience).

You can appeal all the way up the VHA hierarchy, all the way to Washington DC. It is not really an appeal if it is being handled by the Medical Center director. You are also entitled to file a complaint through your local Congressperson's office. I can tell you, when a Director gets a "Congressional" things get addressed pretty quickly...we usually have 48 hours to get back to the Director with a written response to send to the Congressperson's office.

(KLD)

The SCI-Nurses are advanced practice nurses specializing in SCI/D care. They are available to answer questions, provide education, and make suggestions which you should always discuss with your physician/primary health care provider before implementing. Medical diagnosis is not provided, nor do the SCI-Nurses provide nursing or medical care through their responses on the CareCure forums.